Provider Demographics
NPI:1225875974
Name:MOORE, SHAWANDA LASSETTTE (MSN, BS, RN)
Entity type:Individual
Prefix:MS
First Name:SHAWANDA
Middle Name:LASSETTTE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MSN, BS, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10636 3RD ST N APT D
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-3291
Mailing Address - Country:US
Mailing Address - Phone:813-573-9733
Mailing Address - Fax:
Practice Address - Street 1:10636 3RD ST N APT D
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-3291
Practice Address - Country:US
Practice Address - Phone:813-573-9733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9312768163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty